ImPACT Testing

Regardless of age and profession, motor vehicle accidents and falls are the most common ways that people can sustain traumatic brain injuries. Even first responders – police, fire, and ambulance crews – regularly go into harm’s way and risk personal injury that includes concussions, as recently happened when two firefighters in New Jersey slipped while jumping off their fire engine at a house fire.

Even firefighters and other first responders are vulnerable to concussions (Photo: AP/Wide World)

Although sports like football, soccer, and lacrosse get a majority of the press about head traumas and traumatic brain injuries, most of the traumatic brain injuries that we see in HeadFirst Concussion clinics are due to everyday events such as slips and falls and motor vehicle accidents.

Some doctors tell me that the “concussion craze” is going to burn out soon. However, I think the way concussion specialists and medical providers diagnosis and treat traumatic brain injuries will continue to evolve. Other clinicians believe that education, evaluation and treatment of mTBIs will continue to grow in different directions.

Some considerations for the future may include:
– people who carry weapons, work with hazardous materials, or are employed in high-risk jobs could require baseline neurocognitive testing with their employment physical in the event they suffer a brain injury
– schoolchildren of all ages, including the elementary school level, may receive education, baseline testing, while training may be required for all parents and coaches about traumatic brain injuries (it is presently only required for high school kids)
– employers may insist employees to get baseline neurocognitive testing prior as a condition of employment

What we have found in HeadFirst Concussion clinics is that 60-70% of mTBIs are not sports related and more than 95% of our injured patients have not had baseline neurocognitive testing. While concussions continue to make the news and diagnosis increase as public awareness spreads, we encourage people of all ages to schedule a baseline neurocognitive test.

CTE’s connection to football has been in the news for five years now, with a debate centered around whether the number of concussions will affect long-term health and well-being of those playing the sport. Likewise, I’m constantly asked by patients and parents what the future effect of this or future concussions will be on their health. A recent study released by researchers at the Boston University School of Medicine (such as Dr. Robert Cantu, Dr. Ann McKee, Chris Nowinski and others) will probably give moms and dads across America a moment of pause before starting a collision sport like football or hockey.

An answer may lie in a concept developed by these researchers called the Cumulative Head Impact Index (CHII). They found individuals who had more hits to their heads—regardless of whether they had a concussion or not, were significantly (i.e., not even close…a large statistic margin) more likely to experience later-life cognitive problems, apathy and depression. The caution here is that the sample size was only 93 individuals and the exposure was only to football.

The next step is for medical providers and concussion specialists to help families begin to connect the dots throughout the developmental hurdles of a child’s life. For example, the health outcomes for two 7th grade beginning hockey players if they have a different history. One student may have fallen off a changing table as an infant and suffered a skull fracture, have been in a motor vehicle accident, and have fallen multiple times during winter sports, while the other 7th grader may not have suffered any head injuries or significant head trauma. Baseline neurocognitive testing like the ImPACT® test might look different on these two young students, and the outcome and recovery time of any current injuries sustained by each of them could be considerably different.

I’ve often said that kids can’t live in a bubble as much as parents are sometimes inclined to want to wrap their kids in bubble wrap. Young people—really, people of all ages—are going to be in car accidents, bike accidents, and slip and fall just going through life. Parents need to make their own unique, informed decision about how much additional risk of physical injury to which they want to expose their child, given his or her medical history and athletic abilities.

Since HeadFirst Sports Injury and Concussion Care launched just three years ago, we’ve already seen the tide turn about the public’s understanding of concussion (mild Traumatic Brain Injury or mTBI). We’ve gone from hearing “It’s a only a mild concussion,” and “You just got your bell rung a bit,” to an acknowledgment of the severity of this silent injury.

Locally here in the Capital region, HeadFirst has been extremely active in hosting educational seminars for coaches and parents, and participating in dozens of community outreach programs.

In 2014 alone, HeadFirst’s team of professionals participated in more than 80 community events reaching more than 180,000 people. These events included partnerships and sponsorships with the Brain Injury Association of Maryland, Hockey for Heroes (benefitting the Wounded Warrior Project, USA Warriors Ice Hockey Program and Disable Veterans of America), Sports Legacy Institute, Touchdown Club of Annapolis, as well as educational seminars for school and county recreational coaches and athletic directors, presentations for school nurses on concussions and mental health, and attendance at community health fairs.

These groups have welcomed our educators with open arms to help their coaches and athletic trainers understand the right protocol in managing a suspected head injury, from those critical first moments to long-term treatment for proper healing.

Our outreach programs are one of our cornerstones, we’d like to think they’ve helped change the traditional way of thinking about concussions.

HeadFirst is also a gathering point for professionals from around the region to share their expertise. Our monthly Concussion Consortium pulls together physicians, neurologists, neuropsychologists, physical and vision therapists, and other specialists, school administrators and nurses, athletic trainers and coaches, who discuss scientific research and resources for concussion treatment and protocols.

The Consortium often hosts a respected guest speaker who shares information about specific topics and issues related to concussion. Next week, we’re welcoming Sarah Loeffler, LCSW-C, of The Neuropsychiatry Program at Sheppard Pratt Health System in Baltimore, Md., who will discuss mTBI’s connection to anxiety and depression.

Also next week, HeadFirst Chief Executive Officer Robert G. Graw, Jr., M.D., and HeadFirst Program Director Tony Doran, Psy.D., are presenting their lecture, An Integrated Community Model for Concussion: Update, at the Brain Injury Association of Maryland’s annual conference.

Of course, all of this is in addition to our 11 clinics throughout the DC-Baltimore region, which is our reason for existence. From the thousands of neurocognitive ImPACT® tests we’ve administered to the patients for whom we have cared, we’ve heard amazing, heartfelt stories of the trials of living with a concussion and the willpower to overcome it. These serve as our inspiration to push ever forward.

We continue to read emotional articles in the news about concussion awareness, including yesterday’s announcement of San Francisco 49er linebacker Chris Borland’s decision to retire due to the high potential of long-term brain injury from playing. Turning away from a lucrative career in the name of your health surely must be one of the most incredibly difficult decisions to make, and we applaud this young man for having the guts to make this choice.

HeadFirst Sports Injury and Concussion Care is proud to honor March’s designation as Brain Injury Awareness Month, as well as Brain Injury Awareness Day today, March 18. Looking back, it’s been a fulfilling journey, albeit a short one. The starting line is still in our sights and we know the finish line is a long way off—and very likely will continue to move even as we do.

Concussions can and do happen to anyone, anytime, anywhere. The non-discriminatory nature of this injury is what continues to motivate us to do our work.

One of the most common questions that I get from parents is “How well will my child’s helmet protect against concussion?”

The elusive answer appears to have been provided at the 2014 American Academy of Neurology’s annual meeting. In a study co-authored by Frank Conidi, MD, DO, MS, director of the Florida Center for Headache and Sports Neurology, Assistant Clinical Professor of Neurology at Florida State University College of Medicine, the standard drop test was modified to measure linear and rotational responses in crash test dummies to repeated 12 mile-per-hour impacts.

They found that helmets do protect the player from massive injuries like skull fractures in the range of 70 to 80 percent but provide little to no protection against concussion in the range of 10 to 15 percent.

Why is that? While the helmet does its job in disbursing the impact of a hard hit across the helmet to greatly reduce the risk of a skull fracture at one specific site, a helmet cannot stop the brain from shaking inside the skull, thus providing little to no protection against a concussion.

In fact, the team of scientists found that football helmets, on average, reduce the risk of traumatic brain injury by only 20 percent compared to not wearing a helmet. Added to these statistics, Conidi says, “Alarmingly, those that offered the least protection are among the most popular on the field.”

One of the best tools we have available is neurocognitive baseline testing. With the beginning of the school year upon us, please remember to get your child baseline tested. Headfirst Concussion Care offers free ImPACT® baseline testing. Please call 1-855-748-4868 (SIT-IT-OUT) or visit us online to arrange your child’s appointment.

This week’s Healthy Kids and Safe Sports Concussion Summit at the White House had the President addressing the increasing number of mild traumatic brain injuries (mTBI). With the White House now focusing on the situation, surely, word is getting out and parents, coaches and trainers are taking this diagnosis seriously, aren’t they?

Unfortunately, though, even with national-level attention, some folks still aren’t getting the message.

Just this week, I saw a BMX (bicycle motocross) parent whose child has suffered a concussion. During our conversation, I heard phrases like “it was only a little concussion” and “everybody gets a little dinged,” proving that the BMX community is another sport where we can still make inroads. HeadFirst Concussion Care is committed to doing just that by attending local and state BMX championship events to educate fans, parents and coaches that mTBI is truly a serious injury.

Another recent case involved a parent who was reluctant to admit her daughter had a concussion, despite advice from several HeadFirst health providers. Several of us had noted oculomotor deficiencies (when the patient has trouble with movement of the eye) and recommended a referral to an ophthalmologist. Four weeks later, the child still had not been taken to the specialist.

After a follow-up exam, I demonstrated to the young patient’s parents that she had bilateral lower field deficits and used the ImPACT test to demonstrate deficits in her peripheral field. For the second time, I emphasized to the parents the importance of following our recommendations and in getting their young child to have an eye examination.

Despite all the press about concussions, I’m still seeing encounters like these all too often. So, what can we do?

One solution may involve a change in semantics. Instead of words like “concussion” and “mild traumatic brain injury,” use terms like “significant neurological event that involves a change in mental status” or “traumatic brain injury that involves (x) symptoms.”

Additionally, emphasize to parents that concussions are a silent injury. Many of them would treat a broken bone or sprained ligament with more care than they would a brain injury. But, a brain injury should be taken just as seriously, if not more so, as a visible wound.

It is recommended to get a good night’s sleep on a regular basis, but how much is considered a “good” amount? How long do you sleep? I am mainly asking high school and college athletes here. And I know sometimes it is easier said than done when you factor in homework, sports, other extracurricular activities….maybe even a job!

Picture this: You are eager to start your season. Then your coach or athletic trainer tells you to take a baseline test. You may have heard about it from other students or not at all. Most schools and many organizations, including HeadFirst Concussion Care, are using the ImPACT® baseline test to measure the way an athlete’s brain functions, including cognitive thinking, memory and reaction time. The computerized test takes about 25 minutes to complete (as cited in Lovell, 2010) and is intended to give your coach, trainer, and provider a baseline measure of your normal brain function. In the unfortunate event of a concussion, you will take the ImPACT test over time (usually every office visit) to help your healthcare provider, coach, athletic trainer, and teachers make proper decisions for school and returning to play as you recover.

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Okay, back to the subject at hand. Now it is the night before the baseline test. How long should you sleep? A recent study published in the American Journal of Sports Medicine reported that athletes who slept fewer than seven hours before the baseline performed worse on three of four ImPACT scores and reported more symptoms related to their brain injury (as cited in McClure, et al., 2014).

Here’s the bottom line: it is important to get enough sleep on a regular basis, aiming for more than seven hours. If you do not get enough sleep before your ImPACT test, it may not represent your academic ability at its best, especially if you have to go through the entire day and take it after school. Many times in the HeadFirst clinic, I have seen the results of a patient’s test after a suspected concussion better than his or her baseline! Remember, this is a serious matter so make sure to put your best effort forward. I hope you found this helpful and would like to hear your thoughts.

Tips for Getting a Good Night’s Sleep

Having trouble falling or staying asleep? Here are some helpful advice for healthy sleep habits:

Keep a regular bedtime routine every night

Do not exercise or eat a heavy meal three hours prior to going to bed

Do not drink or eat foods with caffeine three hours prior to going to bed

Avoid naps. If you are tired and must take a nap, make sure it is a short nap and not close to your bedtime.

Rest and unwind before heading to bed. Avoid stimulating television shows or video games.

Make sure your room is quiet, comfortable, and without bright lights.

If you do not go to sleep after 30 minutes, try reading , listening to music, or other quiet activities to encourage relaxation.

Ms. Holland typically works at HeadFirst Waugh Chapel clinic. She received her Bachelor of Science in Physician Assistant Studies/Certificate in Primary Care at Howard University. Ms. Holland is a Board-certified Physician Assistant and is a member of the American Academy of Physician Assistants and an American Academy of Physician Assistants Veteran’s Caucus Member.

There is no doubt about it whether it is football, soccer, wrestling, cheerleading, tennis or race cars, athletes love their sport. Therefore, the last thing they want to do is sit out of a game, match, competition, or race. It is a hard but necessary step in recovering from a concussion and preventing second-impact syndrome.

Dale Earnhardt Jr. is learning this first hand. In late August he had his 1st concussion from a crash on a raceway in Kansas. He thought he was okay. He felt good, but on October 7th, he sustained another concussion from another, less severe crash. His symptoms returned. He saw his doctor for a headache that would not go away. Dr. Perry made the right decision and would not allow him to race last weekend or in the race this weekend either. Perry wanted Earnhardt, Jr. to be evaluted by professionals, and Earnhardt, Jr. is lucky to have such a proactive team. They spent Tuesday at University of Pittsburgh Medical Center’s Sports Medicine Concussion Program consulting with Dr. Micky Collins, a concussion specialist, formulating a return to play that included ImPACT testing before returning to the raceway.

Earnhardt talks about needing someone else (his doctors) to make the decision for him not to race because the love of racing would keep him behind the wheel even though he knows that concussions are serious. Our athletes are no different. As parents and coaches, we owe it to our athletes to be that “voice of reason” when we suspect a concussion. From the moment we even think our athlete has sustained a concussion, they must SIT IT OUT! Even though it is hard, we must be proactive in protecting our brain…we only have one for life.